Emergency Department Protocol Research Articles

Standardized Approaches to Syncope Evaluation for Reducing Hospital Admissions and Costs in Overcrowded Emergency Departments

PurposeThe evaluation of syncope is often disorganized and ineffective. The objective of this study was to examine whether implementation of a standardized emergency department (ED) protocol improves the quality of syncope evaluation.Materials and MethodsThis study was a prospective, non-randomized study conducted at a 1900-bed, tertiary teaching hospital in South Korea. We compared two specific periods, including a 12-month observation period (control group, January-December 2009) and a 10-month intervention period after the implementation of standardized approaches, comprising risk stratification, hospital order sets and establishment of a syncope observational unit (intervention group, March-December 2010). Primary end points were hospital admission rates and medical costs related to syncope evaluation.ResultsA total of 244 patients were enrolled in this study (116 patients in the control group and 128 patients in the intervention group). The admission rate decreased by 8.3% in the intervention group (adjusted odds ratio 0.31, 95% confidence interval 0.13-0.70, p=0.005). There was a cost reduction of about 30% during the intervention period [369000 Korean won (KRW), interquartile range (IQR) 240000-602000 KRW], compared with the control period (542000 KRW, IQR 316000-1185000 KRW). The length of stay in the ED was also reduced in the intervention group (median: 4.6 hours vs. 3.4 hours).ConclusionStandardized approaches to syncope evaluation reduced hospital admissions, medical costs and length of stay in the overcrowded emergency department of a tertiary teaching hospital in South Korea.

A Compassionate Care Checklist

Those who know me may be surprised by what I am writing. I am not soft and cuddly. I do not give hugs easily or frequently. I am an avid practitioner of gallows humor. But lately, even my insensitive self has been struck by an undertone of caregiver alienation. By alienation, I mean estrangement or a loss or lack of sympathy for our patients. There is an Us, and there is a Them. And “they,” our patients, do not seem to make sense to us. The alienation frequently appears as follows. The trainee will present a case to me, starting with, “I don’t know why this patient is here ….” Often the patient has a minor complaint that does not seem to warrant a 3 a.m. visit to the emergency department (ED). But there is almost always a reason, a hidden fear. When I ask the trainee about this, I am likely to receive a puzzled look, as if to say, “He’s here for a fever, like I said.” When I ask the patients or their parents the same question, it is there, waiting. “I’m scared of fevers because my brother died of meningitis.” Telling the patient’s parents how to treat a viral-induced fever is palliative; telling them their child is not going to die from meningitis is therapeutic. Another frequent scenario is the difficult patient or family. I am usually alerted to the presence of a difficult patient by some grousing in the charting area. “This mother is such a witch,” or “This father is just plain mean.” These descriptions are usually painfully accurate, and delivering care in these cases is not easy or pleasant. However, the provider anger and surprise surrounding such patients always interests me. Is it really so hard to understand how a mother becomes a witch on her 30th ED trip for her child’s chemotherapy-induced fever and neutropenia or why a father is mean after a 3-hour wait with a crying child in his arms? When my husband was diagnosed with metastatic pancreatic cancer, I had many opportunities to see health care from the other side. One day, when we were in pre-op testing prior to his Whipple procedure, my husband passed out while having his blood drawn. As the anesthesiologist ran into the room for the “code,” he yelled out “Get this guy to the emergency room, his surgery is canceled.” My first response was revulsion. Having seen my husband vasovagal from prior blood draws, I knew he was ok. But what was not ok was the sudden cold reduction of my husband of 17 years to “this guy.” The anesthesiologist, who did not know I was a medical provider, gave no thought to canceling my husband’s lifesaving procedure, nor any inclination to comfort us as he attempted to do so (the Whipple was not canceled and my husband is doing beautifully). Since then, I have been on the lookout for such moments, where we as providers lose the recognition of the personhood of the people we are treating. Compassionate care is not a luxury just for oncologists. Nor does it have to be a time-intensive indulgence. It is literally just the recognition, “I could be you.” Maybe most of us need a bit of hardship, which usually comes with advanced age, before we are capable of such recognition. Yet I will argue that physicians who attempt to see themselves in their patients deliver better and more effective care to their patients. Patients who feel heard are less likely to complain about their ED visits and perhaps less likely to feel the need to return for another one. So, in this checklist era, I propose the following ED protocol for compassionate care: Assume your patient has been waiting a while to see you. Start off with a sentence that acknowledges that you are aware that his/her time is important, too, and you have not been squandering it. Assume your patient is scared. He or she may seem angry or withdrawn. He or she may seem controlling or obstructive. Most of this is likely born of fear. Try to be understanding. For the few patients that are just plain mean, try to ignore it. Assume there is a reason that your patient has come to the ED. It may not be a reason that you think is cogent, but it still needs to be addressed. Assume your patient is intelligent, which is not the same things as educated. Explain why you have made the care plan you have made. Ask if there are barriers that would make your care plan difficult. If steps 1 through 4 fail you, assume the patient is your mother, brother, or best friend. Act accordingly.

(P1-2) Incidence and Pre-Hospital Care of Acute Coronary Syndrome in Emergency Department Banja Luka

IntroductionThe acute coronary syndrome is a leading cause of heart death among adults. The treatment of such patients begins during the first contact with the doctor who is in most cases neither an internist or cardiologist, but an emergency medicine specialist or general practitioner working in the emergency department. For that reason it is of great importance to educate doctors who will be able to establish a fast and precise diagnosis, start therapy and organize quick transport to the nearest catheterization room or coronary unit.ObjectiveThe primary objective was to measure frequency of patient's visits to the Emergency Department because of an acute coronary syndrome. The Secondary objective was to examine the choice of treatment in pre-hospital conditions.MethodologyThrough the statistical retrospective analysis we collected the data from the Emergency Department protocols for the period between June 1, 2008 and December 31, 2008.ResultsIn 14,986 patients during the six-month period, 343 of them had acute coronary syndrome. Men were more affected ((59.5%) than women (40.5%). Most cases belonged to the age group from 65 to 80 years (39.6%) and prevalence after 50 years shows abrupt growth. According to the diagnoses, most patients had unstable pectoral angina (42%) and then followed stenocardia (31%) and AIM (27%). Other therapy included NTG (22%), antihypertensives (21%), acetyl-salicylic acid (20%), analgesics (13%), antiarrhythmics (4%). Fifty-seven percent of the patients had complications. STEMI was diagnosed in 69% of patients, and most often the anterior wall was involved (35%).ConclusionThe diagnosis of acute coronary syndrome was established in 343 patients based on the clinical image, electrocardiographic changes and level of cardiospecific enzymes (troponin T).

Implementation of Goal-Directed Therapy for Children With Suspected Sepsis in the Emergency Department

Suboptimal care for children with septic shock includes delayed recognition and inadequate fluid resuscitation. To describe the implementation of an emergency department (ED) protocol for the recognition of septic shock and facilitate adherence to national treatment guidelines. Root-cause analyses and morbidity and mortality conferences identified system problems with sepsis recognition and management. A group of ED and critical care physicians met to identify barriers and create solutions. To facilitate sepsis recognition, a computerized triage system alarmed on abnormal vital signs, and then toxic-appearing children or children at high risk for invasive infection were placed in a resuscitation room. To facilitate timely delivery of interventions, additional nursing, respiratory therapy, and pharmacy personnel were recruited. Fluids were administered via syringe delivery; standardized laboratory studies and antibiotics were ordered and prioritized. Frequent vital-sign measurements and interventions were documented on a graphical flow sheet to facilitate interpretation of physiologic response to therapy. After protocol initiation, there were 191 encounters in 167 patients with suspected sepsis. When compared with children seen before the protocol, time from triage to first bolus decreased from a median of 56 to 22 minutes (P < .001) and triage to first antibiotics decreased from a median of 130 to 38 minutes (P < .001). The protocol resulted in earlier recognition of suspected sepsis and substantial reductions in both time to receipt of time-sensitive interventions and a decrement in treatment variation.

Statewide Efforts to Narrow the Rural–Urban Gap in Acute Stroke Care

Rural-urban gaps in stroke care remain challenging in part because of the lack of resources, personnel, and necessary infrastructure. The purpose of this study was to assess changes in the acute stroke diagnosis and treatment capacity among rural hospitals before and after implementation of a regionwide stroke initiative. In 2004, the Montana Cardiovascular Health Program partnered with stroke stakeholders throughout the state and surveyed hospitals in Montana and northern Wyoming to assess the availability of technology, services, and personnel for acute stroke care. The Montana Stroke Initiative (MSI) developed protocols, educational material, and stroke awareness campaigns to address the geographic disparities identified in the survey. From 2004 to 2006, protocols and educational material were made available on a website and distributed to rural and critical-access hospitals throughout the region. Stroke awareness campaigns were completed, and MSI members conducted acute stroke care training of prehospital, nursing, and primary providers throughout the region. A follow-up survey in 2008 assessed changes in the stroke systems of care between 2004 and 2008. Data were analyzed in 2009. There were significant increases in availability of prehospital stroke screens, written emergency department protocols, computed tomographic scanning capability, acute stroke teams, and community stroke awareness programs. A systematic statewide effort to improve stroke care led to improved acute stroke care capabilities in necessary infrastructure in rural facilities and a narrowing of the gap between these facilities and the urban facilities.

Striking Rural-Urban Disparities Observed in Acute Stroke Care Capacity and Services in the Pacific Northwest

The age-adjusted stroke death rate in adults aged ≥45 years is significantly higher in the Northwest region than in the rest of the United States. Alaska, Idaho, Montana, Oregon, and Washington have substantial rural and frontier areas with unique characteristics and complexities that pose challenges to timely acute stroke care and ultimately affect the patient. A regional needs assessment was conducted to assess acute stroke care capacity and services in the Northwest region. Hospitals with an emergency department were surveyed with a standardized online tool based on the Brain Attack Coalition recommendations and developed by stroke neurologists, emergency medical services leaders, state public health professionals, and American Stroke Association members. Approximately 76% of hospitals completed the questionnaire. Striking rural-urban differences were seen with rural hospitals having a much lower capacity to adequately care for patients with stroke. Two thirds lacked the necessary personnel, one third lacked necessary neuroimaging equipment, and one fourth were functioning without written emergency department and tissue plasminogen activator stroke protocols. This survey represents the first comprehensive regional assessment of stroke care capacity and services both in the Northwest region and the whole United States. The findings have confirmed the need to focus on strengthening stroke personnel, increasing access to care, and promoting written protocols, especially in rural settings. Additionally, promoting stroke center certification, increasing the number of stroke registries throughout the region, encouraging use of inpatient stroke care protocols in rural hospitals, and conducting ongoing stroke care capacity and services surveys is highly recommended.

201: Does an Emergency Department Protocol to Treat Diabetic Ketoacidosis Decrease the Length of Stay In the Hospital?

201: Does an Emergency Department Protocol to Treat Diabetic Ketoacidosis Decrease the Length of Stay In the Hospital?

Pain in the emergency department: adherence to an implemented treatment protocol.

Although pain is one of the most common presenting complaints in the Emergency Department (ED), pain management is often inadequate. Pain management protocols have been shown to be useful. The objective of this study was to assess the adherence to an already implemented pain management protocol in an urban ED. Secondary analysis of a prospective single centre cohort study on patient preferences for analgesia in the ED. Patient charts were reviewed with a focus on selection, timing and dosage of analgesics according to a visual analogue scale (VAS) on arrival and during the ED stay. Three hundred and thirty-seven patient charts were reviewed. The adherence to the implemented pain management protocol was 42% at the time of initial evaluation and 43% during the course of therapy in all patients. Forty-two percent of the study population were discharged with at least moderate pain. However, 43% of the patients discharged with pain did not request analgesics. The benefits of pain management protocols are proven. However, adherence to these protocols needs to be monitored regularly in order to optimise pain management.

Pain in the emergency department: adherence to an implemented treatment protocol.

Although pain is one of the most common presenting complaints in the Emergency Department (ED), pain management is often inadequate. Pain management protocols have been shown to be useful. The objective of this study was to assess the adherence to an already implemented pain management protocol in an urban ED. Secondary analysis of a prospective single centre cohort study on patient preferences for analgesia in the ED. Patient charts were reviewed with a focus on selection, timing and dosage of analgesics according to a visual analogue scale (VAS) on arrival and during the ED stay. Three hundred and thirty-seven patient charts were reviewed. The adherence to the implemented pain management protocol was 42% at the time of initial evaluation and 43% during the course of therapy in all patients. Forty-two percent of the study population were discharged with at least moderate pain. However, 43% of the patients discharged with pain did not request analgesics. The benefits of pain management protocols are proven. However, adherence to these protocols needs to be monitored regularly in order to optimise pain management.

Room for (Performance) Improvement: Provider-Related Factors Associated With Poor Outcomes in Massive Transfusion

Massive transfusion (MT) protocols improve survival in patients with exsanguinating hemorrhage. Both the increased plasma to red blood cells (RBC) and platelets to RBC ratios, and the "protocolization" of product delivery seem to be critical components of the reduction in mortality. The purpose of this study was to identify the incidence and impact of MT protocol noncompliance and to intervene in provider-related events associated with poor compliance and outcomes. A MT protocol was initiated in 2006 at a Level I trauma center. All cases of protocol activation were reviewed by a multidisciplinary performance improvement (PI) group for compliance and the need for "real-time" protocol adjustments. Educational conferences, Grand Rounds presentations, and individual provider education were performed on a quarterly basis. Compliance of seven measures were evaluated as follows: type and screen sent from emergency department (ED), activation of protocol in ED, activation by trauma attending, administration of 2:3 plasma to RBC, administration of 1:5 platelets to RBC, protocol discontinuation on leaving operating room, and no products wasted. Univariate, multivariate, and time-series analyses were performed. All 125 MT protocol activations occurring from February 2006 to January 2008 were reviewed. Full compliance for all PI measures during the entire period was 27%. There were no differences in demographics, injury severity, or physiologic scores between patients for whom activations were compliant and those who were noncompliant. Full compliance was an independent predictor of survival (86.7% vs. 45.0%, p < 0.001). Both activation of the protocol in the ED and achievement of prespecified ratios of plasma: RBC (2:3) and platelets: RBC (1:5) were independent predictors of 24-hour and 30-day survivals. All PI measures demonstrated improved compliance during the study period with the exception of ED activation. Failure to send type and screen from the ED is an independent predictor of wasted blood products. Early activation of a MT protocol and achieving predefined ratios was associated with improved survival. ED activation and direct blood bank notification by the trauma attending were associated with a reduction in blood product wastage. A multidisciplinary PI process helps to identify provider/specialty noncompliance and to assess the impact of these factors, and it was associated with improvement in compliance and MT outcomes over time.

223: Emergency Department Bedside Ultrasound Measurement of Caval Index as Non-Invasive Determination of Low Central Venous Pressure: A Multi-Center Validation of an Emergency Department Protocol

An initial study has shown that among critically ill adult emergency department (ED) patients undergoing central venous catheterization, a greater than 50% decrease in the inferior vena cava (IVC) diameter measured by experienced emergency physician sonographers is a good predictor of low central venous pressure (CVP). This is preliminary data from a study that seeks to validate this protocol at an additional center among emergency physician sonographers of varying experience.

Emergency Contraception Services for Adolescents: a National Survey of Children's Hospital Emergency Department Directors

Study Objective To assess emergency contraception (EC) counseling and prescribing practices of children's hospital emergency department (ED) directors and the use of EC protocols in these settings. Design Cross-sectional study of children's hospital ED directors responding to a 15-minute 44-item semi-structured survey during telephone interviews. Participants 50 of 96 eligible directors of children's hospital EDs in the United States. Main Outcome Measures EC protocols, EC counseling processes, EC prescribing practices. Results Most (80%) ED directors reported always offering EC as part of sexual assault care; 66% were more likely to provide onsite EC in these situations. Only 52% identified the progestin-only regimen as the EC dispensed in their ED, and most (96%) limited provision to fewer than 120 hours after sex. Although 58% of ED directors reported ever prescribing ongoing contraception when providing EC, none had prescribed EC for future use. Written ED protocols for providing EC were more common for sexual assault care (76%) than for non-sexual assault care (14%). Directors who worked at hospitals with a sexual assault program were less likely to discuss all the recommended topics for EC counseling. Conclusions The recommended standard of care for providing EC to adolescents in children's hospital EDs is not being met. Although risk of pregnancy following sexual assault and consensual unprotected sex is identical, discrepant practices emerged from this survey of pediatric ED directors. Increased education and policy initiatives within children's hospital EDs are needed to standardize EC services for adolescents in this setting.

Impact of a rapid access protocol on decreasing door-to-balloon time in acute ST elevation myocardial infarction

Ischemic cardiovascular disease is the leading cause of death in Canada. In ST elevation myocardial infarction (STEMI), time to reperfusion is a key determinant in reducing morbidity and mortality with percutaneous coronary intervention (PCI) being the preferred reperfusion strategy. Where PCI is available, delays to definitive care include times to electrocardiogram (ECG) diagnosis and cardiovascular laboratory access. In 2004, the Cardiac Care Network of Ontario recommended implementation of an emergency department (ED) protocol to reduce reperfusion time by transporting patients with STEMI directly to the nearest catheterization laboratory. The model was implemented in Frontenac County in April 2005. The objective of this study was to assess the effectiveness of a protocol for rapid access to PCI in reducing door-to-balloon times in STEMI. Two 1-year periods before and after implementation of a rapid access to PCI protocol (ending March 2005 and June 2006, respectively) were studied. Administrative databases were used to identify all subjects with STEMI who were transported by regional emergency medical services (EMS) and received emergent PCI. The primary outcome measure was time from ED arrival to first balloon inflation (door-to-balloon time). Times are presented as medians and interquartile ranges (IQRs). Statistical comparisons were made using the Mann-Whitney U test and presented graphically with Kaplan-Meier curves. Patients transported under the rapid access protocol (n = 39) were compared with historical controls (n = 42). Median door-to-balloon time was reduced from 87 minutes (IQR 67-108) preprotocol to 62 minutes (IQR 40-80) postprotocol (p < 0.001). In our region, implementation of an EMS protocol for rapid access to PCI significantly reduced time to reperfusion for patients with STEMI.

201: Implementation of a Therapeutic Hypothermia Protocol in a Community Hospital Emergency Department

Therapeutic hypothermia (TH) has been shown to improve both survival and neurological outcome in patients after ventricular fibrillation (VF) arrest. Few studies have attempted to replicate these results outside of the research setting, or for patients presenting with other arrhythmias. Our objective was to determine if instituting a TH protocol in a community hospital emergency department (ED) for all patients with neurologic impairment after resuscitated cardiac arrest regardless of presenting rhythm would provide a similar mortality benefit.

Prospective External Validation of the Clinical Effectiveness of an Emergency Department-Based Early Goal-Directed Therapy Protocol for Severe Sepsis and Septic Shock: Jones AE, Focht A, Horton JM, Kline JA. Chest 2007;132:425–32

This study sought to determine whether implementation of an early goal-directed therapy (EGDT) protocol in the Emergency Department (ED) would be effective in reducing mortality from severe sepsis and septic shock. Clinical data and mortality rates were recorded for 1 year before and after implementing an EGDT protocol in an urban ED. In the year before the EGDT protocol, all treatment decisions were left to the emergency physician. In the year after initiation of the protocol, all patients who had suspected or confirmed infection and met two or more of the systemic inflammatory response syndrome criteria and showed evidence of shock were treated according to the EGDT algorithm while in the ED.

Coping With a Child With Dravet Syndrome: Insights From Families

Dravet syndrome is a truly catastrophic childhood-onset epilepsy. Families are faced with repeated episodes of status epilepticus, intractable seizures, mental handicap, behavior disorders, and a life of dependency; understandably, coping with Dravet syndrome is very difficult. Twenty-four families with a child with Dravet syndrome were interviewed and identified some practical suggestions to improve their daily life. These included inserting an indwelling venous access device, creating a portable microenvironment, writing an emergency department protocol, establishing emergency routines for the family, assigning a parent on call to lessen the effect on siblings, creating personal time to decrease parental stress, finding respite care, and contacting an Internet support group. Unresolved and common issues included transition to adult care, the utility of early diagnosis, and social isolation. These solutions and issues may be helpful to many families with a child with Dravet syndrome and possibly other severe childhood-onset epilepsies.

Nonpharmacologic Pain Management Strategies in the Pediatric Emergency Department

Youth often arrive in the emergency department (ED) in a state of emotional and physical distress. This distress is exacerbated by unfamiliar environmental stimuli, perceived threat of procedures, and general discomfort inherent in many medical procedures. Pain itself is a highly individualized experience that is most effectively treated via a multimodal, multisystem approach. For this reason, it is imperative that nonpharmacologic pain and stress management strategies are a part of standard ED protocol. Cognitive-behavioral interventions aim to reduce fear, minimize distress and pain, and increase a child's and parents' sense of control. Emergency department staff should be trained on ways to prepare a child for a procedure. After preparation, youth can benefit from being offered brief training in coping strategies. Upon discharge, families should be equipped to continue implementing these newly learned skills at home and during future hospitalizations. This article offers the reader specific strategies to use with youth presenting to an ED.

Management of Pain Due to Vaso-Occlusive Crisis (VOC) in Adults with Sickle Cell Disease (SCD) in the Post-Guideline Era: A Retrospective Study in an Urban Medical Center Emergency Department (ED).

Guidelines for managing pain due to VOC published in the United States in 1999 and in England in 2003 suggest1.prompt initiation of parenteral opioids (within 30 min of arrival);2.use of an adequate opioid starting dose (5–10 mg or 0.1 mg/kg of morphine intravenously);3.frequent opioid administration (every 15–30 min) with dose titration if pain is not improved; and4.individualization of treatment based on the patient's prior opioid response history.The impact of these guidelines on actual practices has not been assessed however. Thus, the treatment of adults with uncomplicated VOC at a major urban medical center ED during calender year 2005 was reviewed. The ED protocol during this period called for prompt pain reduction using 4–16 mg of IV morphine every 10–30 minutes according to patient specific protocols. Patients on chronic long-acting opioids, with a history of substance abuse, or with impaired renal or hepatic function were excluded from analysis. A total of 58 visits by 20 patients were evaluable. Inpatient admission was required after 25 visits (43%). Of these admissions, 12 occurred after only 1–3 opioid doses (48%) and 8 occurred within 2 hours of initiating therapy (32%). Opioid treatment was begun within 30 min of arrival in the ED on only 10 occasions (18%) and patients were not treated for >2hr on 18 occasions (32%). Similarly, the interval between the first and second opioid dose was ≤30 min in only 16 of 54 evaluable visits (30%) and >1 hr in 15 of them (28%). Subsequent doses tended to be more frequently delayed with only 6 of 39 patients (15%) receiving a third opioid dose within 30 min of their second treatment. The initial treatment dose was 0.19±0.11 mg/kg of parenteral morphine equivalents with a range of 0.05–0.50 mg/kg. Individual patients tended to receive the same initial dose at each ED visit with 9 usually treated with doses of 0.05–0.1 mg/kg (45%) while 6 consistently required doses >0.2mg/kg (30%). However, dose titration during an ED visit was limited. Thus, in the 10 patients receiving an initial dose <0.1 mg/kg and at least 2 subsequent doses, only 6 (60%) received higher doses during their ED stay and dose escalations did not occur prior to the third dose in 4 of them. Indeed, 2 of these patients did not have an increase in dose until the 4th and 7th treatment respectively. Conversely, another patient eventually admitted to the hospital received an initial dose of 0.11 mg/kg but the subsequent 2 doses were only 0.05 mg/kg each. When comparing ED visits which resulted in hospital admission with those in which the patient was able to go home, no significant differences were noted in the mean values for the time to first treatment, time between doses, initial opioid dose or cumulative opioid dose. In summary:1.both the time to initiation of opioid therapy and the intervals between dosing were usually significantly longer than guideline recommendations;2.loading dose requirements in individual patients vary greatly with many patients requiring more than twice the usually recommended dose;3.the decision to admit a patient is often made after only a very brief trial of analgesic therapy; and4.dose titration in patients with more refractory symptoms is often not done or delayed.These findings suggest that, despite protocols consistent with current guidelines, timely, effective therapy of VOC in SCD may be compromised in the setting of an overburdened urban ED resulting in delayed pain control and possibly avoidable hospital admissions.

112: Patient-Controlled Analgesia for Sickle Cell Patients in the Emergency Department Results in Early Pain Management and Increased Patient Satisfaction

The management of sickle cell painful episodes in the emergency department (ED) remains challenging for patients, providers and institutions. In particular, sickle cell patient satisfaction of care in the ED has been low. Objective: To determine whether a directed ED protocol including early administration of intravenous opioids and patient-controlled analgesia (PCA) in the ED would enhance adult sickle cell patient satisfaction.

Impact of organizational infrastructure on β-blocker and aspirin therapy for acute myocardial infarction

Although organizational change has been advocated as a critical component of quality improvement, there is little data available on the variation and effectiveness of organizational elements in the care of acute myocardial infarction (AMI). This study was designed to examine the impact of organizational infrastructure on the use of aspirin and beta-blockers during and after AMI. We assessed organizational infrastructure for AMI care in 44 hospitals in Kansas and linked these data to patient-specific process of care data collected in Kansas as part of the Cooperative Cardiovascular Project. While controlling for clustering within hospitals, we examined the relationships between hospital infrastructure and use of aspirin and beta-blocker both at admission and discharge. Hospitals varied widely in their inclusion of aspirin and beta-blockers in AMI pathways, protocols, and standardized order sets. Hospitals also varied in the involvement of their physicians in AMI quality improvement and in their ability to identify a physician champion for AMI care. Patients were more likely to receive aspirin on admission in hospitals that included aspirin in their emergency department order sets (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.01-2.48) and were more likely to receive beta-blockers on admission and at discharge if beta-blockers were included in an emergency department protocol or pathway (OR 2.14, 95% CI 1.25-3.77 and OR 3.5, 95% CI 1.14-14.38, respectively). Use of beta-blockers at discharge was also associated with commitment of administration to AMI care and the presence of a physician champion. Quality improvement efforts should include a close examination of the organization of AMI care to assure that critical elements in the care of AMI patients are not inadvertently omitted.